Maternal-Fetal Medicine — MCQs

A 31-year-old woman presents with abdominal pain and vaginal spotting, which began 2 days ago and has been worsening. The spotting started this morning. Her last menstrual period was 6 weeks ago. She has no medical problems, takes no medications, and has no known drug allergies. Her vital signs are: temperature 37°C (98.6°F), blood pressure 90/50 mm Hg, pulse 110/min, and respirations 14/min. Abdominal examination reveals significant lower abdominal tenderness. Speculum examination shows scant blood in the vagina with a closed cervical os. Bimanual examination demonstrates significant left adnexal tenderness. Urine hCG is positive, and serum hCG is 5,000 mIU/mL. Pelvic ultrasound shows a normal uterus with a left adnexal mass surrounded by free fluid. In MOST cases, the disease process of this patient affects which of the following anatomic structures?

Q148Easy

Administration of antiretroviral therapy during the peripartum period decreases the risk of vertical transmission by what percentage?

Q149Medium

Pregnancy is contraindicated in which of the following conditions?

Q150Medium

What is true about the indications for the prevention of Rh isoimmunization?

Maternal-Fetal Medicine Indian Medical PG Practice Questions and MCQs

Question 141: Routine pelvic examination is contraindicated in which of the following conditions?

A. Carcinoma cervix
B. Cord prolapse
C. Placenta previa (Correct Answer)
D. Pregnancy-induced hypertension

Explanation: **Explanation:** The correct answer is **Placenta previa**. **1. Why Placenta Previa is the correct answer:** In placenta previa, the placenta is implanted in the lower uterine segment, partially or completely covering the internal os. Performing a routine digital vaginal examination (PV) can cause mechanical separation of the placenta from the uterine wall or trauma to the highly vascular placental tissue. This can trigger **sudden, massive, and life-threatening maternal hemorrhage**. Therefore, a digital examination is strictly contraindicated unless placenta previa has been ruled out by ultrasound. If an examination is absolutely necessary (to confirm the diagnosis in a clinical setting), it must be done under the **"Double Setup"** protocol in an operating theater prepared for an immediate Cesarean section. **2. Why the other options are incorrect:** * **Carcinoma Cervix:** Pelvic examination (including speculum and digital) is essential for staging (FIGO staging) and biopsy. While it may cause minor contact bleeding, it is not contraindicated. * **Cord Prolapse:** A vaginal examination is actually **necessary** to diagnose cord prolapse and to manually displace the presenting part upwards to relieve pressure on the cord until a Cesarean section can be performed. * **Pregnancy-Induced Hypertension (PIH):** There is no contraindication to pelvic examination in PIH. Management focuses on blood pressure control and monitoring for preeclampsia/eclampsia. **Clinical Pearls for NEET-PG:** * **The "Golden Rule":** In any case of antepartum hemorrhage (APH), the first step is to perform a per-abdominal examination and ultrasound; **never** perform a PV examination until placenta previa is excluded. * **Stallworthy’s Sign:** A drop in fetal heart rate when the head is pressed into the pelvic inlet, suggestive of posterior placenta previa. * **Investigation of Choice:** Transvaginal Ultrasound (TVS) is the gold standard for diagnosing placenta previa (safer and more accurate than transabdominal).

Question 142: All of the following are predictors of preeclampsia except?

A. Roll over test
B. Serum uric acid
C. Weight gain > 2kg per month
D. Shake test (Correct Answer)

Explanation: **Explanation:** The **Shake Test** (also known as the Foam Stability Index) is a bedside test used to assess **fetal lung maturity**, not to predict preeclampsia. It involves mixing amniotic fluid with 95% ethanol and shaking it; the persistence of a ring of bubbles at the air-liquid interface indicates the presence of sufficient surfactant to prevent Respiratory Distress Syndrome (RDS). **Analysis of Predictors of Preeclampsia:** * **Roll-over Test:** This is a clinical screening test performed between 28–32 weeks of gestation. A rise in diastolic blood pressure of **>15 mmHg** when the patient moves from a left lateral to a supine position indicates a positive test and increased risk for preeclampsia. * **Serum Uric Acid:** Hyperuricemia (due to decreased renal clearance) is one of the earliest biochemical markers of preeclampsia. While it has low sensitivity for prediction, it is a strong indicator of disease severity and fetal prognosis. * **Weight Gain:** Excessive weight gain (>2 kg/month or >0.5 kg/week) in the second trimester is often due to occult edema and fluid retention, serving as an early clinical warning sign before the onset of hypertension and proteinuria. **Clinical Pearls for NEET-PG:** * **Gold Standard for Prediction:** Uterine Artery Doppler (noting the presence of a **diastolic notch** at 20–24 weeks) is a highly specific predictor. * **Biochemical Markers:** Low levels of **PAPP-A** and **PlGF** (Placental Growth Factor), and high levels of **sFlt-1**, are modern predictive markers. * **Prophylaxis:** In patients with positive predictive tests, low-dose **Aspirin (150 mg)** started before 16 weeks reduces the risk of early-onset preeclampsia.

Question 143: Gas in the aorta after intrauterine fetal death (IUFD) is which sign?

A. Robert sign (Correct Answer)
B. Spalding sign
C. Ball sign
D. Blair-Hartley sign

Explanation: **Explanation:** The correct answer is **Robert sign**. This sign refers to the presence of gas (usually carbon dioxide) within the fetal heart or large vessels, most commonly the **aorta**. It is one of the earliest radiological signs of intrauterine fetal death (IUFD), appearing as early as 12 hours after death. The gas is produced by the decomposition of fetal blood and is typically visualized on an X-ray or ultrasound. **Analysis of Incorrect Options:** * **Spalding sign:** This is the most famous radiological sign of IUFD. it refers to the **overlapping of fetal skull bones** caused by the liquefaction of the brain and loss of intracranial pressure. It usually takes 4–7 days after death to appear. * **Ball sign:** This refers to the **hyperflexion of the fetal spine**, resulting in a "balled-up" appearance. It occurs due to the loss of fetal muscle tone after death. * **Blair-Hartley sign:** This refers to the **constriction of the fetal thorax** or a "collapsed" chest wall, another secondary sign of maceration and loss of internal structural integrity. **NEET-PG High-Yield Pearls:** * **Earliest Sign:** Robert sign (12 hours) is seen earlier than Spalding sign (days). * **Gold Standard:** Today, the diagnosis of IUFD is confirmed via **Ultrasonography (USG)** by demonstrating the absence of fetal heart activity. * **Deuel’s Halo Sign:** Another sign of IUFD where a radiolucent halo appears around the fetal head due to edema of the scalp (subcutaneous fat). * **Clinical context:** Always check for maternal coagulation profile (Fibrinogen levels) if a dead fetus is retained for >4 weeks to monitor for Disseminated Intravascular Coagulation (DIC).

Question 144: Which of the following conditions is NOT associated with increased maternal serum AFP levels?

A. Open neural tube defects
B. Meningomyelocele
C. Spina bifida
D. Trisomy (Correct Answer)

Explanation: **Explanation:** Maternal Serum Alpha-Fetoprotein (MSAFP) is a glycoprotein produced initially by the yolk sac and later by the fetal liver. It serves as a crucial screening marker during the second trimester (15–20 weeks). **Why Trisomy is the Correct Answer:** In pregnancies affected by **Trisomy 21 (Down Syndrome)** and **Trisomy 18 (Edwards Syndrome)**, MSAFP levels are characteristically **decreased**. The exact pathophysiology is not fully understood, but it is attributed to reduced synthesis by the fetal liver and a smaller-than-normal yolk sac. In Down Syndrome screening (Triple/Quadruple test), low MSAFP is typically seen alongside low unconjugated estriol (uE3) and elevated hCG/Inhibin-A. **Why Other Options are Incorrect:** * **Open Neural Tube Defects (ONTDs):** These include conditions where the fetal skin is not intact, allowing AFP to leak from the fetal circulation into the amniotic fluid and subsequently into the maternal serum. * **Meningomyelocele & Spina Bifida:** These are specific types of ONTDs. In these conditions, the failure of neural tube closure results in high concentrations of AFP leaking into the maternal blood, leading to **increased** MSAFP levels. **High-Yield Clinical Pearls for NEET-PG:** * **Causes of Increased MSAFP:** ONTDs (Anencephaly, Spina bifida), Abdominal wall defects (Omphalocele, Gastroschisis), Multiple gestations, Renal anomalies (Finnish-type nephrosis), and **Underestimation of gestational age** (most common cause). * **Causes of Decreased MSAFP:** Trisomies (21, 18), Gestational Trophoblastic Disease (Molar pregnancy), Maternal obesity, and **Overestimation of gestational age**. * **Next Step:** If MSAFP is elevated, the first step is a **targeted ultrasound** to rule out dating errors or multiple pregnancies.

Question 145: All are true in HELLP syndrome except?

A. Hemolysis
B. Elevated liver enzymes
C. Low platelets
D. Develops only in cases of maternal hypertension (Correct Answer)

Explanation: **Explanation:** HELLP syndrome is a severe multisystem complication, traditionally considered a variant of preeclampsia. The acronym stands for **H**emolysis, **E**levated **L**iver enzymes, and **L**ow **P**latelets. **Why Option D is the correct answer (the false statement):** While HELLP syndrome is strongly associated with preeclampsia, it **does not develop only in cases of maternal hypertension.** Approximately **15–20%** of patients with HELLP syndrome are normotensive and do not exhibit proteinuria at the time of diagnosis. This makes it a "great masquerader," as the absence of hypertension can lead to a dangerous delay in diagnosis. **Analysis of other options (True statements):** * **A. Hemolysis:** This is a hallmark feature, characterized by microangiopathic hemolytic anemia. Peripheral smears show **schistocytes** (fragmented RBCs) and helmet cells. Lab markers include elevated LDH (>600 U/L) and indirect bilirubin. * **B. Elevated Liver Enzymes:** This occurs due to periportal necrosis and hepatic sinusoids being obstructed by fibrin deposits. AST and ALT are typically elevated to ≥70 U/L. * **C. Low Platelets:** Thrombocytopenia (Platelets <100,000/mm³) results from increased platelet consumption and activation. **NEET-PG High-Yield Pearls:** * **Mississippi Classification:** Classifies HELLP based on the nadir of the platelet count (Class 1: <50k, Class 2: 50k–100k, Class 3: 100k–150k). * **Clinical Presentation:** The most common symptom is **epigastric or right upper quadrant pain** (due to Glisson’s capsule stretch). * **Definitive Treatment:** Delivery of the fetus (usually after 34 weeks or if maternal/fetal condition deteriorates). * **Complication:** Beware of **hepatic subcapsular hematoma**; sudden hypotension in a HELLP patient suggests rupture.

Question 146: What is the normal range of Amniotic Fluid Index (AFI)?

A. 2 to 8 cm
B. 5 to 8 cm
C. 2 to 24 cm
D. 5 to 24 cm (Correct Answer)

Explanation: The **Amniotic Fluid Index (AFI)** is a semi-quantitative assessment used to monitor fetal well-being. It is calculated by dividing the uterus into four quadrants using the umbilicus and the linea nigra as landmarks, then summing the vertical depth (in cm) of the largest pocket of fluid in each quadrant. ### **Explanation of Options** * **Correct Answer (D) 5 to 24 cm:** In clinical practice, an AFI between **5 cm and 24 cm** is considered the normal physiological range. * **AFI < 5 cm** is the diagnostic threshold for **Oligohydramnios**. * **AFI > 24 cm** (or 25 cm in some texts) is the threshold for **Polyhydramnios**. * **Option A & C (2 cm):** The value "2 cm" refers to the **Single Deepest Pocket (SDP)** or Maximum Vertical Pocket (MVP) method. An SDP < 2 cm indicates oligohydramnios, while an SDP > 8 cm indicates polyhydramnios. * **Option B (5 to 8 cm):** This range is too narrow. While an AFI of 5–8 cm is sometimes termed "borderline" or "low-normal," it is not the standard definition of the entire normal range. ### **High-Yield Clinical Pearls for NEET-PG** * **Gold Standard:** While AFI is commonly used, the **Single Deepest Pocket (SDP)** is often considered superior in twin pregnancies and for reducing unnecessary interventions in post-term pregnancies. * **Peak Volume:** Amniotic fluid volume peaks at approximately **34–36 weeks** (roughly 800–1000 mL) and gradually declines thereafter. * **Common Associations:** * **Oligohydramnios:** Renal agenesis (Potter sequence), PROM, and Placental insufficiency. * **Polyhydramnios:** Gestational diabetes, Tracheoesophageal fistula, and Anencephaly.

Question 147: A 31-year-old woman presents with abdominal pain and vaginal spotting, which began 2 days ago and has been worsening. The spotting started this morning. Her last menstrual period was 6 weeks ago. She has no medical problems, takes no medications, and has no known drug allergies. Her vital signs are: temperature 37°C (98.6°F), blood pressure 90/50 mm Hg, pulse 110/min, and respirations 14/min. Abdominal examination reveals significant lower abdominal tenderness. Speculum examination shows scant blood in the vagina with a closed cervical os. Bimanual examination demonstrates significant left adnexal tenderness. Urine hCG is positive, and serum hCG is 5,000 mIU/mL. Pelvic ultrasound shows a normal uterus with a left adnexal mass surrounded by free fluid. In MOST cases, the disease process of this patient affects which of the following anatomic structures?

A. Cervix
B. Fallopian tube (Correct Answer)
C. Ovary
D. Peritoneal cavity

Explanation: **Explanation:** The patient presents with the classic triad of **ectopic pregnancy**: amenorrhea (LMP 6 weeks ago), abdominal pain, and vaginal bleeding. Her clinical presentation—hypotension (90/50 mmHg), tachycardia (110/min), and free fluid on ultrasound—strongly suggests a **ruptured ectopic pregnancy**, a surgical emergency. **Why the Fallopian Tube is Correct:** In approximately **95–98%** of ectopic pregnancies, the blastocyst implants within the **fallopian tube**. Within the tube, the **ampulla** is the most common site (70%), followed by the isthmus (12%), fimbriae (11%), and interstitium (2%). The lack of a gestational sac in the uterus despite a serum hCG above the discriminatory zone (>2,000–3,500 mIU/mL) and an adnexal mass confirms the diagnosis. **Why Other Options are Incorrect:** * **A. Cervix:** Cervical pregnancies are rare (<1%) and typically present with painless vaginal bleeding and a "hourglass" shaped uterus. * **C. Ovary:** Ovarian pregnancies occur in only 1–3% of cases. They are often confused with hemorrhagic corpus luteum cysts. * **D. Peritoneal cavity:** Primary abdominal pregnancy is extremely rare (approx. 1%). While the "free fluid" (hemoperitoneum) is located in the peritoneal cavity, it is a *consequence* of the tubal rupture, not the primary site of the disease process. **NEET-PG High-Yield Pearls:** * **Most common site overall:** Ampulla of the Fallopian tube. * **Most dangerous site:** Interstitial/Cornual (due to late presentation and risk of massive hemorrhage from the uterine artery). * **Risk Factors:** Previous ectopic (strongest), PID (most common), tubal surgery, and smoking. * **Management:** If hemodynamically unstable (as in this case), the treatment of choice is **emergency laparotomy/laparoscopy**. If stable and hCG <5,000, medical management with **Methotrexate** may be considered.

Question 148: Administration of antiretroviral therapy during the peripartum period decreases the risk of vertical transmission by what percentage?

A. 30%
B. 50%
C. 65% (Correct Answer)
D. 75%

Explanation: The correct answer is **65% (Option C)**. ### **Explanation** The risk of vertical transmission of HIV from an untreated mother to her child is approximately **25–30%**. The landmark **PACTG 076 trial** established that the administration of Zidovudine (AZT) during the antepartum, intrapartum, and neonatal periods reduces the risk of transmission by approximately **two-thirds (66-67%)**, bringing the transmission rate down to about 8%. In the context of standard medical examinations like NEET-PG, **65%** is the recognized value for this reduction. ### **Analysis of Options** * **Option A (30%):** This represents the baseline risk of transmission in an untreated patient (without any interventions). * **Option B (50%):** This is an underestimate. Monotherapy or short-course prophylaxis provides a more significant reduction than 50%. * **Option D (75%):** While modern Highly Active Antiretroviral Therapy (HAART) combined with a viral load <50 copies/mL can reduce transmission to **less than 1–2%** (a >95% reduction), the specific historical benchmark for peripartum ART efficacy is 65-67%. ### **NEET-PG High-Yield Pearls** * **Most common route of transmission:** Intrapartum (during labor and delivery) is the period of highest risk. * **PPTCT Protocol (India):** All HIV-positive pregnant women should be started on **Lifelong ART** (TDF + 3TC + EFV/DTG) regardless of CD4 count or clinical stage. * **Mode of Delivery:** If the viral load is **>1000 copies/mL** at 36 weeks, a **Pre-labor Cesarean Section** is recommended to further reduce risk. * **Breastfeeding:** In India, exclusive breastfeeding for 6 months is recommended if the mother is on ART, though replacement feeding is preferred only if it is AFASS (Affordable, Feasible, Acceptable, Sustainable, and Safe).

Question 149: Pregnancy is contraindicated in which of the following conditions?

A. Heart transplantation
B. Mechanical valves
C. Pulmonary arterial hypertension (Correct Answer)
D. Marfan syndrome without aortic dilatation

Explanation: **Explanation:** **Pulmonary Arterial Hypertension (PAH)**, regardless of the etiology (including Eisenmenger syndrome), carries an extremely high maternal mortality rate (25–50%). During pregnancy, the physiological increase in cardiac output and blood volume, combined with the fixed pulmonary vascular resistance, leads to right heart failure. Furthermore, the systemic vasodilation seen in pregnancy can worsen a right-to-left shunt, leading to severe hypoxemia and sudden cardiovascular collapse, typically during labor or the early postpartum period. Therefore, PAH is a **WHO Class IV** condition where pregnancy is strictly contraindicated. **Analysis of Incorrect Options:** * **Heart Transplantation:** While high-risk, pregnancy is possible if graft function is stable (usually >1 year post-transplant) and medications are adjusted. * **Mechanical Valves:** These patients require meticulous anticoagulation (due to the hypercoagulable state of pregnancy), but it is not an absolute contraindication. * **Marfan Syndrome without Aortic Dilatation:** Pregnancy is generally well-tolerated if the aortic root diameter is **<40 mm**. Risk increases significantly (WHO Class IV) only if the diameter exceeds 45 mm or if there is a history of aortic dissection. **NEET-PG High-Yield Pearls:** * **WHO Class IV Conditions (Pregnancy Contraindicated):** PAH, severe systemic ventricular dysfunction (LVEF <30%), severe mitral stenosis, severe symptomatic aortic stenosis, and aortic root dilatation >45 mm in Marfan syndrome. * **Most common cause of maternal death in heart disease:** Heart failure. * **Highest risk period:** The immediate postpartum period (due to "autotransfusion" from the contracting uterus increasing preload).

Question 150: What is true about the indications for the prevention of Rh isoimmunization?

A. Administered to the newborn within 72 hours of birth.
B. Required when the baby is Rh-positive and the mother is Rh-negative; can be given up to one month of the baby's age. (Correct Answer)
C. Can be helpful in ABO incompatibility.
D. All of the above.

Explanation: **Explanation:** The prevention of Rh isoimmunization relies on the administration of **Anti-D immunoglobulin** to an unsensitized Rh-negative mother to prevent the formation of antibodies against Rh-positive fetal red blood cells. **Why Option B is Correct:** The standard protocol is to administer Anti-D when an Rh-negative mother delivers an Rh-positive infant. While the ideal window for administration is within **72 hours** of delivery to maximize effectiveness, clinical guidelines (including ACOG and RCOG) state that if it is missed, it should still be given as soon as possible. It provides partial protection even if administered up to **28 days (one month)** postpartum. **Analysis of Incorrect Options:** * **Option A:** While 72 hours is the recommended timeframe, it is administered to the **mother**, not the newborn. Anti-D works by clearing fetal RBCs from the maternal circulation. * **Option C:** Anti-D is specific to the **D-antigen**. It has no role in ABO incompatibility (e.g., Mother O, Baby A/B), as the naturally occurring anti-A and anti-B antibodies in the mother are usually IgM and do not require this specific prophylaxis. * **Option D:** Incorrect because A and C are factually inaccurate. **High-Yield Clinical Pearls for NEET-PG:** * **Standard Dose:** 300 µg (1500 IU) intramuscularly covers up to 30 ml of fetal whole blood (or 15 ml of RBCs). * **Antenatal Prophylaxis:** Routinely given at **28 weeks** gestation to all Rh-negative unsensitized mothers. * **Kleihauer-Betke Test:** Used to quantify the volume of feto-maternal hemorrhage (FMH) to determine if additional doses of Anti-D are required. * **Other Indications:** Miscarriage, ectopic pregnancy, amniocentesis, or external cephalic version (ECV) in an Rh-negative mother.

Practice by Chapter

Fetal Assessment Techniques

Practice Questions

Hypertensive Disorders in Pregnancy

Practice Questions

Intrauterine Growth Restriction

Practice Questions

Multiple Gestation

Practice Questions

Rh Isoimmunization and Other Blood Group Incompatibilities

Practice Questions

Intrauterine Fetal Therapy

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Prenatal Diagnosis and Genetic Counseling

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Placental Abnormalities

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Preterm Labor and Delivery

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Management of Medical Disorders in Pregnancy

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